Wiki Decision for Surgery

[solocoder]

I could sure use some opinions from my learned colleagues.
Would anyone consider this a "decision for surgery":

Outpatient Surgery Discussion: Discussed continued conservative versus outpatient surgical treatment options for the symptomatic bunion. Overviewed pre-operative criteria, intra-operative treatment and post- operative convalescence. Discussed moderate risk factors from this type of surgical intervention. Advised on the risks and benefits of continued conservative treatment. Recommended on normal anesthesia options for this type of surgery.

Patient returns for a "surgery consult" a few weeks to a few months later. Just wondering if that subsequent visit is billable, or has the decision already been made.
Any thoughts are appreciated!

 

[dclark7]

In my opinion, you can't quite tell from this piece of documentation. While surgery was discussed, so was continuing conservative treatment. What did the patient decide, to continue with conservative treatment, get a second opinion or have the surgery?

If the patient wanted to wait and see then it got worse, or if (s)he wanted a second opinion, then I would say no the decision had not been made, the option was discussed, but no decision made. If the patient decided (s)he wanted the surgery and just put it off for awhile, then I'd say the decision was made. depends on the circumstances.

 

[solocoder]

Thank you for your reply dclark7. I guess I am just going to have to have the doctor start documenting it more clearly.

 

[solocoder]

So, to clarify: the "decision for surgery" is made only when the *patient* agrees to go ahead with the surgery, rather than when the *doctor* recommends surgery?